“Establishing a human milk bank in the Birmingham area is very much a public health initiative, and this is a major community outreach program that we have been active in starting and supporting with the goal of improving neonatal and infant health in our region,” Toms said.

According to Toms, the infant mortality rate in Alabama has historically been high.

“There are many positive initiatives around the state aimed at lowering the infant mortality rate with encouraging results,” he said. “Breast milk can improve infant health, optimize growth and development, and potentially reduce illness and death in this high-risk population.”

Low birth weight infants and those born prematurely are at a particularly high risk.

“There are many positive initiatives around the state aimed at lowering the infant mortality rate with encouraging results. Breast milk can improve infant health, optimize growth and development, and potentially reduce illness and death in this high-risk population.”

“The food bank believes passionately that breast milk provided to preterm sick infants will help children get a head start on a healthy development and start those children on the right path,” said Mary Kelley, executive director of The Community Food Bank. “As the conversation around food continues to evolve, one of the most important pieces of the puzzle is the concept of ‘the first food,’ breast milk, and UAB has been a wonderful partner in this initiative. Its leadership, along with that of the Neonatal Intensive Care Unit team, has been pivotal in helping us get this initiative off the ground.”

UAB sponsors initiatives like the Nurturing Mothers’ Group and the Mothers’ Milk Bank of Alabama as part of its efforts to provide the highest-quality care to area mothers and their children.

Providing support to community groups is part of UAB’s Baby-Friendly Hospital Initiative journey. The BFHI is a global program that was launched by the World Health Organization and the United Nations Children’s Fund in 1991 to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding.

The process of handling and pasteurizing donated breast milk is very strict, and Kelley says the Mothers’ Milk Bank will follow the quality-control standards and guidelines set forth by the Human Milk Banking Association of North America.

“The guidelines are extremely strict and maintain a specific protocol to ensure breast milk is processed in a clean, food-grade environment,” Kelley said. “The food bank is skilled at the operations that a milk bank requires: soliciting donors, soliciting product, processing that product and safely distributing it to those in need.”

All donor mothers undergo a preliminary phone questionnaire screening, followed by a blood test. Once they are cleared for donation, milk is donated, pooled together and pasteurized. Following pasteurization, each batch of donor breast milk is then post-cultured to ensure no bacterial growth.

In the history of nonprofit Human Milk Bank Association of North America milk banks, not a single baby has become ill from donor breast milk. In fact, they have thrived.

“This process is very important to us, and we can ensure excellent quality of the milk given to some of our most fragile babies,” Toms said. “In addition to pasteurizing the milk, we will be able to divide the donated milk by nutritional components and calories, enabling us to provide higher caloric milk — or higher protein content — to babies who need it.”

Donated breast milk will be provided to any infants in need throughout the city, regardless of the hospital.

The Southeast has historically been a region of relatively low breast-feeding rates, although Toms says it is a trend that seems to be changing with more mothers feeling strongly about the importance of breast-feeding.

UAB aims to provide the support these mothers need in part because research shows breast milk to be effective in the development of the babies — both pre- and full term.

“Breast milk is so much more than just nutrition,” Toms said. “When a baby is born, the intestines are naïve to the outside world — the world of proteins, carbohydrate, fats, and also bacteria and viruses. Breast milk creates an environment in the neonate’s intestines that optimizes absorption of nutrients.”

Breast milk also presents good bacteria to the infant’s immune system in the intestines in a way that allows the baby’s immune system to develop a balanced memory of its own cells, bacteria and other foreign products.

“This results in a baby who can absorb all nutrients, vitamins and minerals in an optimal manner and develop a well-adjusted immune system that will harmonize with the environment, and thus thrive,” Toms said.

UAB faculty and staff recently joined The Community Food Bank on a site visit to the Mothers’ Milk Bank of North Texas, a mentor and facilitator for Birmingham’s bank. Sylvia Edwards, UAB lead of Lactation Services, says the trip was especially valuable and reinforced the opportunity the Mothers’ Milk Bank of Alabama will provide to families in Birmingham and throughout the state.

“What’s especially great is that we already have mothers here in the area donating their milk,” Edwards said. “We hope anyone interested in learning more about becoming a donor will join us Aug. 26 to learn what a tremendously positive impact this can have on our community.”

Prematurity, low birth weight leading cause for the leveling off of infant mortality and neonatal mortality rates in the United States

A study by University of Alabama at Birmingham (UAB) researchers published April 1, 2013, in the journal Pediatrics showed that increasing numbers of premature and other low birth weight infants are the leading cause for the leveling off of infant mortality and neonatal mortality rates in the United States.

Infant mortality rate is defined as the number of infants who die before their first birthday. Neonatal mortality rate is defined as the number of infants who die before reaching 28 days old.

Researchers concluded the leveling off of these rates is due to increases in live birth registration of smaller and more immature infants, particularly infants with birth weights of less than 500 grams or 1.1 pounds.

“Doctors today are able to keep smaller babies alive due to improved obstetrical and neonatal care,” said UAB Edwin M. Dixon Professor of Pediatrics Wally A. Carlo, M.D., the study’s senior author, director of the UAB Division of Neonatology and director of UAB’s newborn nurseries. “Because of this, more and more small babies are being reported as live births, and a large proportion does survive thanks to medical advances. However, because so many more small babies are being reported as live births, and a number do not survive past their first birthday, the rates of infant and neonatal mortality are not going down as much as they have in the past.”

Throughout the 20th and into the 21st centuries, there has been a steep, continual decline in the number of babies who die before their first birthday. According to previous research published in Pediatrics, from 1915 to 2008, infant mortality rates in the United Sates decreased from 99.9 deaths to 6.6 deaths per 1,000 live births. The neonatal mortality rate decreased from 20.5 in 1950 to 4.3 deaths per 1,000 live births in 2008.

However, infant mortality and neonatal mortality rates in the United States plateaued from 2000 to 2008, from 6.6-7.0 and 4.3-4.7 deaths per 1,000 live births, respectively. Data from the Centers for Disease Control and Prevention shows that from 1983-2005, preterm birth rates increased from 9 percent to 12.7 percent, and the percentage of low birth weight infant births increased from 6.8 percent to 8.2 percent.

“We know that preterm birth and low birth weight are among the most frequent causes of infant and neonatal death in the United States. What we did not know before this study was if the increasing proportion of very preterm births (babies born at less than 28 weeks’ gestation) and very low birth weight (babies weighing less than 3.3 pounds at delivery), particularly those less than 1.1 pound, disproportionately affect mortality rates.

The research team sought to determine the impact of birth weight and the infant’s gestational age at birth on mortality rates.

“We know that preterm birth and low birth weight are among the most frequent causes of infant and neonatal death in the United States,” Carlo added. “What we did not know before this study was if the increasing proportion of very preterm births (babies born at less than 28 weeks’ gestation) and very low birth weight (babies weighing less than 3.3 pounds at delivery), particularly those less than 1.1 pound, disproportionately affect mortality rates.”

Using data compiled by the National Center for Health Statistics, Carlo and the research team looked at birth and infant death data for all the years available, 1983-2005. Years 1992-94 were unavailable in the database and excluded from the study. For the birth-weight specific neonatal and infant mortality rates, the data were analyzed following weight subgroups used in the database: 3,500 grams; 3,000-3,499 grams; 2,500-2,999 grams; 2,000-2,499 grams; 1,500-1,999 grams; 1,250-1,499 grams; 1,000-1,249 grams; 750-999 grams; 500-749 grams; and <500 grams. Infants with unknown birth weight were excluded.

For each year, the percentage of live births, percentage of infant deaths, percentage of neonatal deaths, infant mortality and neonatal mortality rates were calculated for each weight subgroup in the database. The same analysis was done for gestational age using the database subgroups: less than 28 weeks, 28-31 weeks, 32-35 weeks, 36 weeks, 37-39 weeks, 40 weeks, 41 weeks and 42 weeks.

The team then evaluated and compared low birth weight and prematurity trends over two time periods – 1983-1999 and 2000-05 – and their effect on infant and neonatal mortality. Analysis over these time periods, Carlo said, allowed the team to confirm whether or not the mortality rates had significantly changed over time, and to determine the contribution of low birth weight and preterm births to infant mortality and neonatal mortality rates.

The data, the team found, showed an increase in the number of infants in the lower birth weight subgroups and a corresponding decrease in infants that weighed more than 3,500 grams or 7.7 pounds. From 1983-2005, the number of very low birth weight infants — those less than 1,500 grams or 3.3 pounds — increased from 1.2 to 1.5 percent of all births and the proportion of live birth infants weighing less than 500 grams, or 1.1 pounds — increased from 0.12 to 0.18 percent. However, the number of babies born weighing more than 3500 grams, or 7.7 pounds, decreased from 40.1 to 35.1 percent.

Additionally, Carlo said the team learned there was an increase in the number infants born weighing less than 1,500 grams, or 3.3 pounds, and the number of infant deaths from 1983-2005. Similarly, there was an increased in preterm infants born, and a corresponding decrease in term and post-term infants. The analysis confirmed that all of the subgroups of infants born weighing less than 1,500 grams, or 3.3 pounds, and infants born before 28 weeks gestation increasingly contributed to infant deaths from 1983-2005.

Carlo said it is important to point out that while the numbers of spontaneous preterm births of single fetus pregnancies have declined over the last century, there are tangible causes for the increase in premature and low birth weight infants reported in this paper.

“Preterm births in the United States have increased because women are being induced before 37 weeks gestation without a clear medically-necessary indication,” Carlo said. “While a preterm birth might be considered an obstetric success, the benefits of this practice on perinatal mortality and morbidity need to be demonstrated. It is important to note that 23 percent of late-preterm infants do not have a recorded indication for early delivery noted in their birth certificate.Add to this the continuing increase in twin, triplets and higher order births, and you have the root causes of some of the increases in lower birth weight and preterm infants in the U.S. since the late 20th century.”

Carlo added that in international comparison terms, this study showed the United States is not as behind in like countries as the numbers seem. The World Health Organization defines live birth as the expelled product of conception showing evidence of life regardless of the duration of pregnancy, which is also how live birth is defined in the U.S. Because other high-income countries define live birth as birth weight of 500 grams or more, the leveling off of mortality rates is more evident in the United States than in many other countries.

“The analysis clearly showed that the leveling off of infant and neonatal mortality is due to the increased proportion of extremely low birth weight and preterm infants born in the U.S.,” Carlo said. “We were pleased to find that infant and neonatal mortality have continued to decrease, when birth weight and gestational age specific analysis is done, meaning normal birth weight and term infants are surviving past their first birthday in increasing numbers in the U.S.”

Apgar is best known as the developer of the Apgar score, which is assigned to babies worldwide as a measure of their health status at birth. Carlo is an internationally respected neonatologist known most recently for his research in newborn care training for physicians and midwives to prevent infant deaths in developing countries, and for his career-long research endeavors into the best ways to provide respiratory support to even the smallest preemies. The advances he has led, just like those Apgar made, are responsible for helping to save millions of lives every year.

In recognition of these contributions, the American Academy of Pediatrics Section on Perinatal Pediatrics will present Carlo with its 2012 Virginia Apgar Award at the American Academy of Pediatrics National Conference and Exhibition in New Orleans, La., on Oct. 20. The award is given annually to an individual whose career has had a continuing influence on the well-being of newborn infants. As the recipient, Carlo also will open the plenary session of the 2013 American Academy of Pediatrics Spring Meeting as the Butterfield Lecturer.

“This award is a recognition of the many mentors, collaborators and colleagues who have provided me with a nurturing environment and opportunities to develop and evaluate innovative interventions to reduce infant mortality and morbidities,” Carlo says. “I am honored to have been selected among so many outstanding researchers and clinicians.”

The 2012 Virginia Apgar Award is given annually to an individual whose career has had a continuing influence on the well-being of newborn infants.

Carlo is Edwin M. Dixon Professor of Pediatrics at UAB, director of the UAB Division of Neonatology and director of UAB’s newborn nurseries, which include a 63-bed regional neonatal intensive care unit, a 60-bed step-down continuing care nursery and three well-baby nurseries. Carlo also is director of neonatology at Children’s of Alabama, which includes a 48-bed neonatal intensive care unit at the Benjamin Russell Hospital for Children. Working in conjunction, UAB and Children’s of Alabama are classified as a Level IV neonatal intensive care unit, the highest level possible and the only one in the state. It is also the largest neonatal intensive care service in the United States.

“Wally Carlo is extremely deserving of this award,” says Sergio Stagno, M.D., chairman of the UAB Department of Pediatrics and physician-in-chief at Children’s of Alabama. “He is nationally and internationally known and is highly respected. Wally is a caring physician who is dedicated to the care of neonates, particularly the extremely premature infants, to training the next generation of physicians, and to expanding medical knowledge and designing health-care delivery systems that can be adapted to third-world countries. He is a true leader in every facet of neonatology.”

In the 20-plus years Carlo has been with UAB, he has helped make UAB a worldwide leader in neonatology education and leadership. UAB is the only academic medical center in the country that is involved in all three of the NIH research initiatives for maternal, child and family health: the Neonatal Research Network, Maternal-Fetal Medicine Units Network and the Global Network for Women and Children Research.

In the 20-plus years Carlo has been with UAB, he has helped make UAB a worldwide leader in neonatology education and leadership. UAB is the only academic medical center in the country that is involved in all three of the NIH research initiatives for maternal, child and family health: the Neonatal Research Network, Maternal-Fetal Medicine Units Network and the Global Network for Women and Children Research.

Carlo has published more than 250 manuscripts in peer-reviewed journals, including the New England Journal of Medicine, Journal of the American Medical Association, Pediatrics and Obstetrics and Gynecology. He has served on many university, hospital and national professional boards and committees and is a member of numerous professional organizations, including the Society for Pediatric Research and the American Pediatric Society.

Carlo earned his undergraduate degree from the University of Puerto Rico in Mayagüez and his medical degree at the University of Puerto Rico Medical Sciences Campus in San Juan. He completed his pediatric internship and residency at University Children’s Hospital in San Juan, where he was chief resident. He completed a neonatology fellowship at Rainbow Babies and Children’s Hospital in Cleveland and joined the faculty following his fellowship. Carlo is board certified in pediatrics and neonatal-perinatal medicine. He has been with UAB and Children’s of Alabama since 1991.

A low-cost interventiongives even the earliest preemies a chance to survive and thrive.

With chubby cheeks and weighing in at a healthy 10 pounds, the imminently huggable Lexi Morrison is far removed from the 1-pound, 9 –ounce preemie she was in June when she was born premature at 24 weeks.

Giving antenatal corticosteroids in extremely preterm infants like Lexi — those born between 22 and 25 weeks gestation and weighing less than 2 pounds — is associated with significant reductions in death and long-term complications such as neurodevelopmental impairments, including cerebral palsy, poor motor skills and lower intelligence, according to research by Wally Carlo, M.D., director of the UAB Division of Neonatology, published in the Dec. 7, 2011, issue of the Journal of the American Medical Association.

Freeman knew she was at risk for premature labor; doctors placed a stitch in her cervix to keep it closed when she was 20 weeks pregnant, and she immediately went to the hospital when she began bleeding at 23 weeks. Several days later, at 24 weeks and two days, Lexi was born.

“I had problems before, and I lost a premature baby. I didn’t want it to happen again,” Freeman says. “They asked me if I wanted to use the steroids and I told them yes — whatever is better for Lexi I want to do it. They got two (doses) in me before she was born.”

Antenatal corticosteroids, when given to a woman in preterm labor, mature the lungs and other organs in the baby’s body. Two shots of the steroids have been recommended for women in premature labor as early as 24 weeks, but there were no data for 23 weeks or earlier gestation from randomized, controlled trials, Carlo says. And the data was quite limited in trials for pregnancies between 24 and 25 weeks.

“There also was very limited data on long-term outcomes for these babies; this is significant because it is important to increase survival and also to increase the quality of life,” he says. “We wanted to study the smallest premature babies because this is a very large population of infants, but the practice of giving antenatal corticosteroids to women at these gestational ages differs from physician to physician.”

Carlo also says there have been concerns about giving antenatal corticosteroids to some women in early premature labor, especially those susceptible to infection, because steroids lower the body’s ability to fight infection.

The study, funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and conducted by Carlo for the Neonatal Research Network, used data collected prospectively on babies born between January 1993 and January 2009 at 22 to 25 weeks gestation weighing between just under a pound to 2 pounds at 23 academic medical centers across the country. Carlo and his research team ultimately wanted to determine if antenatal corticosteroids worked as well in early premature babies, even in the long term, as they do in babies born at 26 weeks gestation and older.

“The results of the study showed that mortality was decreased by more than 33 percent and neurodevelopmental impairment was decreased by more than 20 percent,” Carlo says. “It seems that extremely premature infants, from 22 to 25 weeks, can respond as well as infants that are more mature. We also found that using the antenatal corticosteroids did not increase the infection rate for the mothers.”

Carlo says the study is important because it shows that a low-cost intervention, about $25 for two shots, gives even the earliest preemies a chance to survive and thrive.

“Delivery of a normal baby is an emotional occasion, and delivery of a premature baby is even more emotional. The ability to tell parents there is a treatment that has such major benefits is very comforting,” Carlo says. “They know there is something that can be done.”

Freeman is grateful for the opportunity at life antenatal corticosteroids gave her daughter.

“It was very easy, simple,” she says. “I’m very grateful. I thank God every day for it.”

Premature babies are at greater risk for myriad health complications than babies delivered at full-term, and one of the most common causes of death is infection, says Wally Carlo, M.D., director of the UAB Division of Neonatology. Carlo is co-author of the report on the Heart Rate Observation System (HeRO), a technology used to assess high-risk infants.

“Using the Heart Rate Observation System, we were able to analyze multiple variables of the heart rate and calculate an index that estimates the risk of developing infection — before the infants show clinical manifestations,” Carlo says.

“HeRO is the first non-invasive technique for early detection of infection in such a high-risk population. It is a novel technology that gives real-time results instead of waiting on blood tests at a critical time,” Carlo says.

UAB Hospital was one of eight hospitals in the United States in which the system was studied in a randomized, controlled trial that included more than 3,000 patients treated from April 2004 to September 2010.

Modified oxygen delivery device can provide safe, cost-effective life-saving therapy to infants and children in developing nations where pneumonia is the leading killer.

Wally Carlo

Pneumonia is the leading cause of infant deaths worldwide, but pediatric researchers at the University of Alabama at Birmingham have developed an effective, inexpensive way to help breathe life into children in developing countries.

A paper in the July 4, 2011, edition of the journal Pediatrics by UAB neonatologist Wally Carlo, M.D., and colleagues at other institutions, describes a modified device for adults that can safely be used for low-cost, low-maintenance, low-concentration oxygen therapy in infants and small children.

In some parts of Sub-Saharan African and Southeast Asia the death rate from pneumonia in children under 5 can be 10 times higher than in the United States. Many infants and children with pneumonia and other respiratory conditions need oxygen therapy to survive.

“In the developed world, oxygen is delivered to these patients with devices that blend compressed oxygen and compressed air to provide accurate and precise concentrations and flow rates,” Carlo says. “Use of these blenders in developing countries is hindered by multiple factors, including cost, maintenance and lack of local availability of compressed air. These devices are expensive and somewhat complex, which further limits their use in developing countries.

“This novel system developed at UAB allows delivery of the exact oxygen concentration by pulling air from the environment using a commercially available device,” Carlo says.

The researchers tested a device in a laboratory setting to determine the necessary concentrations and flows of oxygen suitable for therapy for infants and small children using three oxygen delivery systems – a nasal cannula, oxygen hood and oxygen mask.

“We found that using a mask resulted in the delivery of oxygen concentrations that was accurate to the flow the entrainment device showed it was delivering,” Carlo says. “The hood produced a similar profile of concentrations and flow rates but with even greater accuracy but the cannula did not deliver accurate oxygen concentrations.”

Carlo says the findings are important because for the first time these experiments demonstrate that air-blending devices can accurately and precisely deliver set oxygen concentrations at flows lower than those for which they are nominally designed, but only if used with the proper delivery

systems.

Prolonged treatment with higher-than-needed concentrations of oxygen is not appropriate early in life because of the potential risk of blindness, death, cerebral palsy and other conditions.

“It is important to have an oxygen therapy like the one outlined in this paper in these low-tech environments to have a source of oxygen with adjustable concentrations ranging from near atmospheric to pure oxygen concentrations, at varying flow rates, to be able to save the thousands of children in developing countries who each year contract pneumonia and other conditions.”

The investigators are planning clinical trials to give oxygen to infants and children with pneumonia in an attempt to reduce mortality.

This work was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Network for Women’s and Children’s Health Research.

Carlo’s co-authors on the paper are Matthew Coghill, B.S.N.R.E., and Namasivayam Ambalavanan, M.D., of UAB; Robert L. Chatburn, MHHS, RRT-NPS of the Cleveland Clinic, and Patricia L. Hibberd, M.D. of Massachusetts General Hospital; and Linda L. Wright, M.D of the National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Network for Women’s and Children’s Health Research.

For about $200 per child, the seven-day mortality rate for newborns in Zambia dropped by 40 percent.

Each year around the world 3.6 million infants die in the first 28 days of life. The majority of these deaths occur within seven days of birth and 98 percent occur in developing countries.

But basic newborn care and resuscitation interventions could be implemented in a cost-effective manner at health-care facilities in countries with limited financial resources, according to the findings of study by University of Alabama at Birmingham researchers published online April 18, 2011, in Pediatrics.

Previous studies have shown that training personnel in first-level facilities and communities in developing countries using basic neonatal care from the World Health Organization Essential Newborn Care course — routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of the small baby and common illnesses — could save up to 1 million lives each year.

“A major barrier to action on neonatal health has been the erroneous perception that only expensive, highly technological care can reduce mortality,” said study co-author Wally Carlo, M.D., director of the UAB Division of Neonatology. “We have proven through this study that the cost of saving lives is very low – about $200 per child.”

Carlo and his colleagues compared the cost and the outcomes of training midwives who worked in primary care, low-risk health facilities in Lusaka and Ndola, Zambia. The midwives participated in the WHO essential newborn-care course on seven-day neonatal mortality.

They looked at two types of expenses: program-level costs (initial training, training equipment and materials, initial implementation and supervision) and maintenance costs (ongoing supervision, the costs per year for subsequent maintenance of the program). They related these to neonatal mortality in the clinic for both pre-training and post training for the staffs.

A total of 40,615 neonates were enrolled in the study. All-cause seven-day neonatal mortality decreased from 11.5 per 1,000 births before essential newborn-care training to 6.8 per 1,000 births after training; it was associated with a decrease in deaths caused by birth asphyxia and infection. During the post-training period 20,534 neonates survived and did not suffer seven-day early neonatal mortality, reducing neonatal death in Zambia by 40 percent.

“On the basis of this outcome we estimated that a total of 97 lives were saved during the study period, with a cost per life saved of $208,” Carlo said. “The estimated yearly costs to maintain the program, including equipment replacement, training manuals, and personnel was $14,128 per year and cost-effectiveness data like this are needed to guide the development of policies and strategies to accomplish the United Nations’ Millennium Development Goal 4 to reduce childhood mortality by two-thirds by 2015.”

Training midwives in basic neonatal care reduces infant death in the first seven days of life for babies born in health care facilities in developing countries. It also has the potential for saving more than 1 million lives worldwide each year, according to a study and commentary published in the October issue of Pediatrics.

Throughout the world, birth asphyxia, low birth weight or prematurity and infections are major causes of death during the seven days after birth, according to Carlo. The low-cost interventions in this study have already been shown to be effective in preventing stillbirth and perinatal deaths in community births, including home births, in a study published earlier this year in the New England Journal of Medicine, of which Carlo was the lead author. The study in Pediatrics was necessary, he says, to show the same results could be replicated in clinic settings.

Using the train-the-trainer model, local instructors trained birth attendants using the World Health Organization (WHO) newborn-care course (routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of the small baby and common illnesses) and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (in-depth basic resuscitation).

"The midwives were trained to do several easy steps that are critical for babies to survive at birth and be kept alive through the first week of life," Carlo says. "We selected these courses because previous research has shown they contain the essential interventions necessary to sustain life in many infants and are a cost-effective educational package that can be used anywhere in the world."

A total of 71,689 neonates were enrolled in the study; after the midwives received training the seven-day mortality decreased from 11.5 deaths per 1,000 births to 6.8 deaths per 1,000 births.

"The findings show that these two low-cost training programs, whether used in a community or clinic setting, are effective in combating infant mortality in the developing world," Carlo says. "Now we are moving to cost analysis studies to see what resources will be needed to expand the training programs, and we are also following the babies who survived following resuscitation to make sure they are developing well."